Hindawi Publishing Corporation

BioMed Research International

Volume 2016, Article ID 7659016, 4 pages
http://dx.doi.org/10.1155/2016/7659016

Research Article
Self-Perception of Swallowing-Related Problems in
Laryngopharyngeal Reflux Patients Diagnosed with
24-Hour Oropharyngeal pH Monitoring

Tamer A. Mesallam1,2,3 and Mohamed Farahat1,2

1
Department of Otolaryngology, Head and Neck Surgery, King Saud University, Riyadh 11411, Saudi Arabia
2
Research Chair of Voice, Swallowing, and Communication Disorders, ORL Department, College of Medicine,
King Saud University, Riyadh 11411, Saudi Arabia
3
Otolaryngology Department, College of Medicine, Al-Menoufia University, Shebin Al-Koum 32512, Egypt

Correspondence should be addressed to Tamer A. Mesallam; tmesallam@ksu.edu.sa

Received 16 November 2015; Accepted 24 January 2016

Academic Editor: Peter S. Roland

Copyright © 2016 T. A. Mesallam and M. Farahat. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background and Objectives. Swallowing difficulty is considered one of the nonspecific symptoms that many patients with laryn-
gopharyngeal reflux complain of. However, the relationship between laryngopharyngeal reflux and swallowing problems is not clear.
The purpose of this work is to explore correlation between swallowing-related problems and laryngopharyngeal reflux (LPR) in a
group of patients diagnosed with oropharyngeal pH monitoring and to study the effect of laryngopharyngeal reflux on the patients’
self-perception of swallowing problems. Methods. 44 patients complaining of reflux-related problems were included in the study.
Patients underwent 24-hour oropharyngeal pH monitoring and were divided into positive and negative LPR groups based on the
pH monitoring results. All patient filled out the Dysphagia Handicap Index (DHI) and Reflux Symptom Index (RSI) questionnaires.
Comparison was made between the positive and negative LPR groups regarding the results of the DHI and RSI ratings. Also, corre-
lation between DHI scores, RSI scores, and pH monitoring results was studied. Results. Significant difference was reported between
positive and negative LPR groups regarding DHI scores, RSI scores, and overall rating of swallowing difficulty. There was significant
correlation demonstrated between DHI scores, RSI scores, and 24-hour oropharyngeal pH results. Conclusion. Laryngopharyngeal
reflux appears to have a significant impact on patients’ self-perception of swallowing problems as measured by DHI.

1. Introduction
Many laryngeal disorders have been attributed to laryn-
gopharyngeal reflux (LPR) including reflux laryngitis, sub-
glottic stenosis, laryngeal carcinoma, contact ulcers and
granulomas, vocal nodules, and arytenoid fixation [1–4].
Symptoms of LPR include hoarseness, vocal fatigue, excessive
throat clearing, globus pharyngeus, chronic cough, postnasal
drip, and dysphagia [4]. In addition to voice problems,
chronic cough, and throat clearing, swallowing difficulty was
among the main complaints in patients with LPR and it has
negative impact on their quality of life [5, 6].
Silbergleit et al. [7] developed the DHI, which is a patient-
administered 25-item questionnaire that measures the handi-
capping effect of dysphagia on the emotional, functional, and
physical aspects of the patient’s life. DHI was translated into
Arabic language and was found to be a valid and reliable tool
for patients with oropharyngeal dysphagia including patients
with LPR [8].
The oropharyngeal Dx-pH measurement system (Dx-pH;
Restech Corp., San Diego, CA, USA) is considered a mini-
mally invasive and relatively new device that recently has been
used in many research studies concerning the diagnosis of
LPR. The device has been reported to be reliable in the detec-
tion of acidic reflux events in the posterior oropharynx [9–11].
The aim of this study was to explore correlation between
swallowing-related problems and laryngopharyngeal reflux
(LPR) in a group of patients diagnosed with oropharyngeal
pH monitoring and to study the effect of laryngopharyngeal
2 BioMed Research International
reflux on the patients’ self-perception of swallowing prob-
lems.
2. Patients and Methods
2.1. Subjects. The Institutional Review Board at College
of Medicine has approved the study proposal. The study
included 44 patients who were referred to the Reflux Clinic
to perform 24-hour oropharyngeal pH monitoring test.
Adult male and female patients complaining of reflux-related
symptoms were included in the study. LPR-related complain
included change of voice character, frequent throat clearing,
foreign body sensation, or cough. Patients with a reported
swallowing difficulty related to neurological or structural
problems were excluded from the study.
2.2. DHI and RSI Rating. All patients in the study were
instructed to fill out the DHI and RSI before being admitted
to the clinic. Patients were asked to rate the questionnaires
precisely according to their current condition. Patients rated
their swallowing problems in the DHI according to the sug-
gested rating of “never, sometimes, or always.” Ratings were
scored considering 0 for never, 2 for sometimes, and 4 for
always. Also, patients were asked to rate the overall severity
of their swallowing difficulty on a scale from 1 to 7 given that
1 refers to normal or no problem while 7 refers to a severe
problem. Similarly, patients were instructed to fill out the 9-
item RSI on a rating scale ranging from 0 to 5, where 0 means
no problems and 5 means a severe problem. Patients were
given clear instructions about how they will fill out the 2 ques-
tionnaires according to the above-mentioned rating scales.
2.3. 24-Hour Oropharyngeal pH Monitoring. The diagnosis of
laryngopharyngeal reflux in the study group was confirmed
using 24-hour oropharyngeal Dx-pH probe system (Restech
Corp., San Diego, CA). The patients were instructed to keep
their normal daily activity as usual during the study and
were given a diary to record the meal times and recumbent
position times.
Following the 24-hour recording, analysis of the data
was carried out using a software system provided with the
device. Acidic reflux thresholds were set for 5.5 in the upright
position and 5.0 in the supine position; meanwhile the meal
times have been excluded from the analysis. The system
automatically generates the Ryan score, which is a composite
score, calculated based on the given pH thresholds of upright
and supine positions. The score incorporates three main
parameters including number of reflux episodes, the duration
of longest reflux episode, and the percentage of time below
the predetermined pH threshold. Scores greater than 9.41 in
the upright position and/or 6.80 in the supine position were
considered suggestive of LPR [9, 12, 13].
2.4. Statistical Analysis. Patients were divided into positive
and negative LPR groups according to the results of the
oropharyngeal pH monitoring. Comparisons were made
between the positive and negative LPR groups regarding the
results of the DHI, RSI, and overall rating of swallowing
Table 1: Age and gender distribution among the positive and
negative LPR groups.
LPR positive LPR negative
group (𝑁 = 26) group (𝑁 = 18)
Patients (𝑛) 26 18
Age (mean ± SD) 44.80 ± 12.99 46.88 ± 10.19
Gender
Male 𝑛, (%) 10 (26%) 9 (50%)
Female 𝑛, (%) 16 (74%) 9 (50%)
difficulty. Correlation was studied between the results of
oropharyngeal pH-related measures and DHI results.
As a prerequisite of our statistical analysis, a numer-
ical assessment of the normality of data was undertaken.
Kolmogorov test was done to test the normal distribution
of the data. Based on the normality test, all data were
not normally distributed. Thus, nonparametric statistical
analyses were applied. Spearman’s correlation coefficient was
used to test the correlation between variables while Mann-
Whitney test was used for comparison of the DHI, RSI, and
overall swallowing difficulty rating results among the study
groups. The level of significance was set as 𝑃 value <0.05. The
Statistical Package for the Social Sciences, Version 22 (SPSS
Inc, Chicago, IL, USA) was used for all statistical analysis.
3. Results
The study included 44 subjects in the age range between 22
and 67 years old with a mean age of 45.65 years old. There
were 19 male and 25 female subjects who participated in the
study. Based on the 24-hour oropharyngeal pH monitoring
results, 26 patients were diagnosed with positive LPR diagno-
sis while 18 patients had negative LPR diagnosis. Table 1 shows
age and gender distribution of the study subjects among
positive and negative LPR groups.
On comparing the DHI scores between positive and neg-
ative LPR groups, positive LPR group reported significantly
higher DHI scores than that of the negative LPR group (𝑃 <
0.01). Similarly, there were significantly higher ratings for
the overall swallowing difficulty in the positive LPR group
compared to the negative one (𝑃 < 0.001). Moreover, positive
LPR group showed significantly higher RSI scores compared
to the negative LPR group (Table 2).
As shown in Table 3, significant positive correlation was
reported between the DHI total score and RSI score, number
of reflux episodes, and the Ryan score (𝑟 ranged from 0.3 to
0.68). Also, there was significant positive correlation between
the overall swallowing difficulty and RSI score, number of
reflux episodes, and Ryan score (𝑟 ranged from 0.41 to 0.52).
4. Discussion
Dysphagia has been frequently mentioned in the literatures
as one of the presentations of LPR. Moreover it has been
reported that it negatively affects the patients’ quality of life
[2, 14–19]. The aim of this work was to study the effect of
LPR on patients’ self-perception of swallowing difficulties as
BioMed Research International 3

Table 2: Comparison between LPR positive and negative groups regarding the DHI and RSI scores.

LPR positive group (𝑁 = 26) LPR negative group (𝑁 = 18)

Mann-Whitney 𝑃
Mean SD Mean SD
DHI 33.46 17.88 19.44 22.26 <0.01
Overall swallowing difficulty 3.76 1.14 2.11 1.02 <0.0001
RSI 22.69 5.88 11.55 10.43 <0.0001

Table 3: Correlation between the DHI, RSI, and the pH monitoring
results.
Number of
RSI
reflux episodes
Spearman’s rho
DHI
Correlation
0.68∗∗ 0.33∗
coefficient
Sig. (2-tailed) 0.001 0.02
𝑁 44 44
Overall swallowing
difficulty
Correlation
0.52∗∗ 0.45∗∗
coefficient
Sig. (2-tailed) 0.0001 0.002
𝑁 44 44
∗∗
Correlation is significant at the 0.01 level (2-tailed).
∗
Correlation is significant at the 0.05 level (2-tailed).
measured by DHI. Also, to explore the correlation between
LPR and swallowing-related problems in a group of LPR
patients diagnosed with oropharyngeal pH monitoring.
The DHI has been developed to measure patients’ rating
of their swallowing problems. In this study DHI scores were
significantly higher in LPR positive group compared to the
negative LPR group. Also, the overall rating of swallowing
difficulty was significantly higher in positive LPR group com-
pared to the negative one. These findings indicate that LPR
has a negative effect on the patients’ self-perceived swallowing
difficulty. These results confirm the findings of Aviv et al.
[20], as they have suggested that anatomical and physiological
changes in the hypopharynx related to LPR contribute to sig-
nificant abnormalities in swallowing including penetration
and aspiration. They also reported that treatment of LPR with
proton pump inhibitors significantly reduced the number of
aspiration and penetration events.
In this study, we assessed LPR from both subjective and
objective point of view. Objectively, we used the oropharyn-
geal pH monitoring to classify patients into positive and neg-
ative LPR groups while RSI results represent the subjective
impression of patients regarding their LPR problem. Not only
DHI results were higher in the positive LPR group but also
RSI rating was significantly higher compared to the negative
group. This suggests that LPR does not only negatively affect
the DHI rating but also has similar effect on RSI results. These
results emphasize the significant influence of LPR on patients’
quality of life and coincide with the findings of other related
studies assessing the quality of life of patients with LPR [5, 6].
Ryan The positive correlation that has been reported between
the DHI scores and both RSI and pH monitoring results
score
(including number of reflux episodes and Ryan score)
emphasizes the negative influence of LPR on patients’ self-
perception of swallowing problems. Interestingly, the rating
0.30∗ of overall feeling of swallowing difficulty also showed signif-
icant positive correlation with the RSI scores and pH mon-
0.04 itoring results. This signifies that apart from sophisticated
44 dysphagia assessment tools, general feeling of swallowing
difficulty is also negatively affected by LPR. These collective
results reflect the negative effect of LPR on the overall swal-
lowing quality of life issues of patients with such a problem.
0.41∗∗
0.005
5. Conclusion
44
The results of this study indicate that overall feeling of
swallowing difficulties is significantly higher in LPR patients.
There appears a negative effect of LPR on patients’ self-
perception of swallowing-related problems as measured by
DHI.
Conflict of Interests
The authors have no conflict of interests to be reported.
Acknowledgment
The authors extend their appreciation to the Deanship of
Scientific Research at King Saud University for funding this
work through research group no. RGP-VPP-295.
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